“These scaly patches keep coming back and creams barely help — it’s ruining my confidence”

CHRONIC PLAQUE PSORIASIS — well-demarcated, red/salmon-pink plaques with SILVERY scale at extensor sites (elbows, knees), the scalp, and sometimes the lower back/umbilicus, often with NAIL changes (pitting, onycholysis) and a chronic relapsing course — must be managed as MORE THAN SKIN. Confirm the clinical picture and assess extent, severity and sites, then apply the topical TREATMENT LADDER: generous emollients plus a potent topical CORTICOSTEROID + VITAMIN D ANALOGUE (NICE CG153: once daily each, applied separately, for up to 4 weeks; a combined once-daily product only if separate application is not possible) first-line, with site-appropriate preparations (scalp formulations; appropriate agents for flexures/face) and review at 4 weeks, with at least 4-week breaks between courses of potent steroids at one site — recognising that "creams don’t work" is often under-treatment or incorrect potency/application. Know when to STEP UP or REFER to dermatology (extensive/severe, topical-resistant, significant functional/psychological impact, difficult sites → phototherapy, systemics such as methotrexate/ciclosporin/acitretin, biologics) and the rare emergencies (erythrodermic or generalised pustular psoriasis). Critically, SCREEN for PSORIATIC ARTHRITIS — morning joint stiffness/pain, dactylitis, enthesitis, axial symptoms or nail disease (PEST for peripheral joints, which misses axial disease; NICE NG65 inflammatory back pain criteria for the back; joints examined face to face) — and refer to rheumatology if suspected, because early treatment prevents joint damage; do not treat the skin and miss the joints. Recognise psoriasis as a SYSTEMIC condition associated with increased cardiovascular risk and metabolic syndrome (address smoking, weight, alcohol, BP/lipids/glucose, with formal cardiovascular risk assessment for severe psoriasis at presentation and at least every 5 years per CG153) and identify TRIGGERS (stress, infection — e.g. streptococcal/guttate, skin trauma/Koebner, and drugs such as beta-blockers, lithium, antimalarials, plus alcohol). Above all, take the PSYCHOSOCIAL impact seriously — psoriasis profoundly affects confidence, mood, body image, relationships and work, with stigma and real risk of depression/anxiety — so screen low mood and validate the distress rather than treating it as merely cosmetic. The hidden agenda is the visible skin plus the distress and now the joints; optimise treatment, screen arthritis and comorbidity, and address the emotional impact.